Summary: Changes to mental health are challenging to patients and the physicians who treat them. Frequently mental disorders present in an undifferentiated manner and there is insufficient time to conduct a full psychiatric assessment and plan. During the typical 10-20 min. encounter in primary care, the priority is safety, with a focus on identifying risks that may irrevocably impact life, limb and the chance of eventual recovery. Once the main risks are identified and strategies for mitigation implemented other issues such as symptom review and diagnostic clarification can be pursued.

Introduction

Undifferentiated, acute mental disorders or those that have recently changed are inherently complex, challenging and may be anxiety producing for the treating family physician.

There is usually insufficient time to conduct a full psychiatric assessment that includes a comprehensive history of the patient’s concerns, psychiatric symptoms, diagnosis and management plan.

Many concerns compete for the busy family physician’s attention in a typical encounter. As a result, time pressures, the complexity of mental health issues, and the anxiety they might produce in the physician can result in missing key risks to the patient and others.

The solution

How should one prioritize one’s time during the brief primary care encounter?

Safety, as the priority means first focussing on risk and related clinical decisions prior to other issues such as diagnostic clarification and treatment.

Assessment / History

Primary care visits are short and the initial interaction with the patient that includes rapport building, eliciting patient’s concerns and desired outcomes can easily take up the entirety of the appointment. This interaction should serve as a bridge to targeted questions that are focused on risk identification. It is important to remember that it is common to prioritize the patient’s story or explanatory model at the expense of identifying risks that require immediate attention. You do not want the patient to leave the office without having ascertained these risks.

Chief complaint

“What brings you in today?”

Goals

“How can we make this a helpful visit?”

HPI

“Tell me more about what’s been happening…” (start with an open-ended exploration of the patient’s chief concerns)

Risk Assessment

“Thank you for giving me an idea of what’s been going on. I have some more specific questions to ask you…”

Risk to self, e.g. suicide?

“With all that’s been going on, are you having any thoughts that life isn’t worth living?”

Risk to others

“With all the stress, have you been feeling frustrated at others?” “Has it gotten to the point that you’ve had thoughts of hurting others?”

Risk to others on the road

“Any problems driving?”

Functional Impairment

Personal care including basic and instrumental activities of daily living;

“Any troubles looking after yourself?”

Dependents such as children, impaired adults, elderly persons, and pets;

Doctor’s note to school / employer, which recommends accommodations and modifications

Case, Part 2

Risks

You assess John’s suicide risk and decide he does not require immediate admission or medical detoxification.

He states that he is not responsible for his children during the day while his wife is working or before his afternoon shift.

He has never been violent toward anyone in the family.

He does not experience withdrawal symptoms from the alcohol but notices a crash in mood when the cocaine wears off.

John’s safety as a forklift driver is in question and he has been driving his car while high.

You advise him that you have a legal obligation to notify the ministry of transportation regarding John’s licences.

John reveals he has been spending approximately $200 per week on cocaine and alcohol, unbeknownst to his wife.

Physical exam

With respect to his substance use, you examine him and his blood pressure is 160/100 mmHg.

You advise him of his short-term and long-term psychological and physical risks

Investigations

You order appropriate bloodwork.

Feedback

You ask John if he wants help with his substance use, and his other issues

John says yes, particularly given the licensing and financial concerns.

You suggest that John tell his wife about his problems and his spending, and that they return for an appointment together within the next week.

You tell John that his suicide risk will be monitored for worsening over time, pending clarification of the responsible conditions.

You are unable to make any DSM-5 diagnoses as you lack details about his psychiatric symptoms, however you can ask about those a later appointment, if you have time and/or when you call him in for a complete assessment

You start preparing mentally for your next patient, which is an elderly woman who is weak and dizzy………

Conclusion

Remember:

The primary objective in the initial encounter with the patient with undifferentiated mental disorder is risk identification.

Although rapport facilitates the patient’s sharing of information and is thus important, establishing rapport per se is not the primary objective.

Overly focusing on rapport can lead to the failure of identifying risks that require urgent attention.

The antecedents to a problem can be sorted out over time.

Risk mitigation is time sensitive -- as per the old adage, time is of the essence.

Disclaimer

Information in this article is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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Addendum: Sample Recording Sheet

This is a sample sheet to help with writing down responses during a clinical encounter

Risk Assessment

Domain

Sample question for patient

Patient’s responses:

Risk to self, e.g. suicide?

“With all that’s been going on, are you having any thoughts that life isn’t worth living?”

Risk to others

“With all the stress, have you been feeling frustrated at others?” “Has it gotten to the point that you’ve had thoughts of hurting others?”

Risk to others on the road

“Any problems driving?”

Functional Impairment

Domain

Sample questions

Patient Responses

Personal care including basic and instrumental activities of daily living;

“Any troubles looking after yourself?”

Dependents such as children, impaired adults, elderly persons, and pets;